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for a specic condition or disease, situate a healthcare issue in the context of your life as a whole, or address questions or concerns that linger
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Thomas E. Brown, Ph.D., Attention Decit Disorder: The Unfocused Mind
in Children and Adults
Ruth Grobstein, M.D., Ph.D., The Breast Cancer Book: What You Need to
Know to Make Informed Decisions
James Hicks, M.D., Fifty Signs of Mental Illness: A Guide to Understanding
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Catherine M. Poole, with DuPont Guerry IV, M.D.,
Melanoma: Prevention, Detection, and Treatment, 2d ed.
Attention
Decit
Disorder
The Unfocused Mind in Children and Adults
The information and suggestions contained in this book are not intended to replace
the services of your physician or caregiver. Because each person and each medical
situation is unique, you should consult your own physician to get answers to your
personal questions, to evaluate any symptoms you may have, or to receive suggestions on appropriate medications.
The author has attempted to make this book as accurate and up-to-date as
possible, but it may nevertheless contain errors, omissions, or material that is outof-date at the time you read it. Neither the author nor the publisher has any legal
responsibility or liability for errors, omissions, out-of-date material, or the readers
application of the medical information or advice contained in this book.
Copyright 2005 by Thomas E. Brown. All rights reserved. This book may not be
reproduced, in whole or in part, including illustrations, in any form (beyond that
copying permitted by Sections 107 and 108 of the U.S. Copyright Law and except
by reviewers for the public press), without written permission from the publishers.
Designed by Rebecca Gibb. Set in Scala type by Integrated Publishing Solutions.
Printed in the United States of America.
Library of Congress Cataloging-in-Publication Data
Brown, Thomas E., Ph. D.
Attention deficit disorder : the unfocused mind in children and adults /
Thomas E. Brown
p. cm. (Yale University Press health & wellness)
Includes bibliographical references and index.
ISBN 0-300-10641-6 (alk. paper)
1. Attention-decit hyperactivity disorder. 2. Attention-decit disorder in adults.
I. Title. II. Series.
RJ506.H9B765 2005
616.8589dc22
2005040895
A catalogue record for this book is available from the British Library. The paper in
this book meets the guidelines for permanence and durability of the Committee on
Production Guidelines for Book Longevity of the Council on Library Resources.
10 9 8 7 6 5 4 3 2 1
To my wife, Bobbie, with continuing love and gratitude for all you are,
all you give, and all we share together
Contents
Preface xi
Introduction xvii
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Contents
Resources 319
References 323
Index 349
ix
Preface
xii
Preface
Preface
xiii
xiv
Preface
Preface
xv
In Chapter 9, I explain options to alleviate ADD syndrome impairments with treatment. The rst step in any treatment program is to provide accurate information to the patient and family about the nature and
course of ADD impairments. Since ADD syndrome is biochemically
based, the most eective treatment is usually medication. Recently, new
medications and new delivery systems for older medications have been
developed. I outline what is now known about safety, eectiveness, side
eects, and practical aspects of these medication treatments. The usefulness and limitations of behavioral treatments, accommodations, and
other supports for ADD syndrome are also described. I emphasize that it
is important to design for each patient a personalized treatment plan.
In Chapter 10, I provide examples of how untreated ADD syndrome
tends to erode hope, and how it can cause severe suering to individuals
and families. This chapter also describes fears, prejudices, and other factors that are barriers to seeking, obtaining, and sustaining adequate treatment. I contrast strategies that oer unrealistic hope with interventions
that nurture realistic hope in the daily lives of individuals and families
suering from ADD syndrome.
Many children, adolescents, and adults whom I have treated over the past
twenty years have contributed to what is written here. Their names and
identifying data have been removed, but I remain very grateful for their
comments and stories, which have infused my understanding and these
pages with essential details of real life. I also appreciate deeply the encouragement of patients, parents, and professional colleagues as I worked
to write and publish these materials; their enthusiasm has sustained me
during the long process of turning ideas and images into sentences and
paragraphs.
For helpful comments on earlier versions of the manuscript I am indebted to Dr. Jay Giedd, Dr. Anthony Rostain, Dr. Rosemary Tannock, and
Dr. Margaret Weiss. Wendy Hill is the medical illustrator who provided
the excellent drawings that illustrate the text. Our son, Dave Brown, helpfully challenged my hesitations about trying to write for a wider audience
and our daughter, Liza Somilleda, contributed perceptive comments on
xvi
Preface
Introduction
Often people think of focus as holding a camera still and adjusting the
lens for a clear picture of an unmoving object. That is not the meaning of
focus in the title of this book. Rather, focus refers here to a complex, dynamic process of selecting and engaging what is important to notice, to
do, to remember, moment to moment. Much as a careful driver focuses
on the task of driving a car in heavy trac by actively looking ahead while
also checking mirrors, observing road signs, braking, and so on (all while
monitoring dashboard gauges, keeping in mind the speed limit and destination, and ignoring the temptation to look too long at interesting
sights), a person employs this very active, rapidly shifting, repeatedly readjusted deployment of attention and memory as the focus needed to plan
and control ongoing activity. Such focus is extremely dicult for the 7 to
10 percent of the worlds population who suer from a syndrome of cognitive impairments currently known as attention decit disorder (ADD) or
attention-decit hyperactivity disorder (ADHD).
Syndrome is a term that describes a cluster of symptoms that tend
to appear together. For example, nasal congestion, sore throat, headache,
fatigue, and fever often appear together as a syndrome commonly referred
to as a cold. One single cause or a variety of dierent causes might lead
to one common syndrome.
xvii
xviii
Introduction
Introduction
xix
xx
Introduction
Introduction
xxi
Chapter 1
MYTH: ADD is just a lack of willpower. Persons with ADD focus well on
things that interest them; they could focus on any other tasks if they really
wanted to.
FACT: ADD looks very much like a willpower problem, but it isnt. Its essentially a chemical problem in the management systems of the brain.
Most individuals who suer chronically from an impaired ability to pay attention are able to focus their attention very well on activities that interest
them. So why cant they pay attention during other activities that they recognize as important? To answer this riddle, we have to look more carefully
at the many aspects of attention, recognizing that processes of attention in
the human brain are more complex and subtle than we might have imagined. One way to understand the complexity of attention is to listen carefully to patients with ADHD as they describe their struggles with inattention. Meet a patient of mine, a teenaged hockey player whom Ill call Larry:
Larry, a sturdy, sandy-haired high school junior, was sitting in
my oce with his parents as we began our rst session together.
While introducing the family, the parents mentioned that Larrys
hockey team had just won the state championship. Proudly they
told of how well he had played. As goalie he had successfully
blocked thirty-four shots in the championship game and led his
team to victory. Larry smiled modestly, but with obvious and
well-deserved pleasure.
Then Larrys father stated their dilemma. When he is playing hockey, Larry is amazing in how he pays attention to all the
action. He knows where that puck is every second. He protects
the goal and at the same time he watches what the other guys
are doing and helps keep his team organized and motivated. He
is always totally involved and on top of his game.
But at school, his father continued, its an entirely dierent
story. We know that Larry is very bright. His IQ test scores show
hes in the superior range, in the top 3 percent. Usually he scores
high on semester exams and he did very well on the PSAT, but
his day-to-day work and his report card grades are always up and
down, from A+ to almost failing.
We know Larry wants to get good grades. Hes always talking
about how he wants to become a doctor and how he needs to get
his grades up so hell get into a good college and then medical
school. But for years he has been totally inconsistent in his
schoolwork. Once in a while we see him burning the midnight
oil to do some reading or write a paper, but most of the time
he procrastinates and avoids his schoolwork. Were constantly
getting complaints from his teachers, the same frustrations
every year.
They say that once in a while Larry will make some comment in class that shows how smart he is, how well he understands whatever they are working on. Once in a while hell write
an excellent paper or do an amazing job on an assignment. But
most of the time, the teachers are complaining that Larry is uninvolved and out to lunch. Hes not a behavior problem, but he
is gazing out the window or staring at the ceiling. They say that
in class discussions he often doesnt even know what page they
are on. And were always getting reports that his homework is
late or just not done.
How can Larry be so amazingly good at paying attention
to his hockey, and yet be so amazingly poor at paying attention
to his schoolwork?
Larry had been staring at the carpet as his father spoke, but
then he raised his head. His eyes were moist as he quietly said
to his parents, I dont know why it keeps happening. Im just as
frustrated and even more worried about this than you are. When
I saw my last report card, I went to my room and cried.
I know what I have to do and I really want to do it because
I know how important it is for all the rest of my life. I try to get
into it like Im into hockey. Sometimes I can get into it for a
while, for this assignment or that class. But mostly I just cant
make it happen.
I really want to, and I know I should be able to do it; I just
cant. I just cant make myself pay steady attention to my work
for school anywhere near the way I pay attention when Im
playing hockey.
A very similar dilemma was experienced by Monica, a shy girl in fth
grade who hung her head as her mother angrily described to me her problems in school.
Her teachers say she cant pay attention for more than three
minutes at a time. I know thats not true! Ive watched her play
Nintendo. She can play those video games for three hours at a
time without moving. And the teacher says shes easily distracted. Thats nonsense! When shes playing those video
games shes locked onto that screen like a laser. When shes into
those games the only way you can get her attention is to jump in
her face or just turn o the TV.
Ive done everything I can think of to get her to shape up in
school. Ive gotten daily reports from school and praised her
when she did well. Ive tried to bribe her with rewards for good
work. Ive tried punishing her, taking away her Nintendo or making her do long time-outs in her room. None of it works. I know
she can pay attention when she really wants to. I dont know
what else I can do. Shes not a dumb kid and shes not a bad kid,
but if she doesnt start paying attention to her schoolwork pretty
form. But if the task you are trying to do is not intrinsically interesting, if it doesnt turn you on, then you cant get it up. You
cant make it happen. Its just not a willpower kind of thing.
Facets of Attention
What do we mean by paying attention? Over one hundred years ago,
William James wrote:
Everyone knows what attention is. It is the taking of possession
by the mind, in clear and vivid form, of one out of what seem
several possible objects or trains of thought. Focalization, concentration of consciousness [is] its essence. It implies withdrawal from some things in order to deal eectively with others,
and it is a condition which has a real opposite in the confused,
dazed, scatter-brained state which . . . is called distraction.
(1890, vol. 1, pp. 403 404)
James held what I call the spotlight theory of attention: the notion
that attention is a solitary, powerful beam focused by the mind on some
objects or trains of thought (in Jamess words) selected from the many
other perceptions and ideas that might otherwise be attended to in that
same moment.
This spotlight theory is too simple. It describes only certain types of
attentionvisual attention, for example, in which one looks steadily at one
point rather than itting around aimlessly to see many dierent points, or
simple auditory attention, in which one listens to one sound, or a series of
sounds, while ignoring others. But when we look carefully at the descriptions of Larry and Monica, for example, we notice that they do many things
at once. They are not only watching and listening to what is happening on
the screen or on the ice, but also engaging in complex actions that may
occur simultaneously or in rapid-re sequence. As Monica plays her video
games, she is not simply staring at the TV, but also actively monitoring
rapid movements of many objects on the screen, deciding which ones
might enrich or destroy her icon. She responds quickly by pressing control
buttons and guiding her icon with adept movements of the controls. Mon-
ica keeps track of her score and her levels in the game, all while recalling
and engaging strategies useful in earlier games. She also contains her alternating feelings of frustration and triumph so that she can attend to the
game without overreacting to its ever-changing ups and downs.
Likewise, Larrys success on the hockey rink depends on multifaceted
and simultaneously implemented aspects of attention. He not only tracks
the puck in its quick movements around the ice, but also monitors his
teammates and opposing players, trying to anticipate moves and to alert
his defensemen to dangers and opportunities. Simultaneously, he keeps
track of the passage of timehow many minutes or seconds are left in the
period, or how soon a player will be released from the penalty box.
Larry also notices subtle cues of agging eort in his teammates and
calls out to encourage and challenge them. He stops himself from thinking too much about a goal he just blocked or one that just got by him into
the net. He keeps in mind and tries to follow tips given by his coach in
practice last week or during the momentary time out. And he tries to ignore provocative actions and comments from opposing players or spectators. All this and much more is included in Larrys paying attention while
he is playing hockey.
Larrys father suggested even broader meanings of attention when he
spoke of how Larry exercised year round in the gym to stay in shape for
hockey and how he pushed himself hard to build strength, endurance,
and skills during team practices. He elaborated on how Larry planned his
daily schedule to be on time to every practice. And he told of how carefully
Larry managed his equipment, keeping his skates sharp and his pads and
uniform in good repair. He related how this boy attended special training
clinics and studied plays of college and professional goalies so he could
use their strategies to improve his moves on the ice. From this description
it was clear that Larry gave intense and continuing attention to hockey in
a wide variety of complex ways.
The Many Components of Inattention
If attention is more than just a simple beam of focus, we can reason
that inattention is multifaceted as well. When teachers and parents
10
11
12
13
Most of the time hes totally spaced out. Last Saturday he set out
to x a screen upstairs. He went to the basement to get some
nails. Downstairs he saw that the workbench was a mess so he
started organizing the workbench. Then he decided he needed
some pegboard to hang up the tools. So he jumped into the car
and went to buy the pegboard. At the lumberyard he saw a sale
on spray paint, so he bought a can to paint the porch railing and
came home totally unaware that he hadnt gotten the pegboard,
that he had never nished sorting out the workbench, and that
he had started out to x the broken screen that we really needed
xed. What he needs is a lot more awareness of what he is doing.
Maybe that medicine our kids are taking can give him that.
From this wifes description one might conclude that the central problem of ADD is essentially a lack of sucient self-awareness. She seems to
believe that if only her husband were more steadily aware of what he is
doing, he would not be so disorganized, jumping from one task to another
without completing any single one. But most people do not require constant self-awareness to complete routine tasks. For most people, most of
the time, operations of executive functions occur automatically, outside
the realm of conscious awareness. For example, while driving a car to the
local supermarket, experienced drivers do not usually talk themselves
through each step of the process. They do not have to say to themselves:
Now I put the key in the ignition, now I put my foot on the brake, now I
turn on the engine, now I check my mirrors and prepare to back out of my
driveway, and so on. Most experienced drivers move eortlessly through
the steps involved in starting the car, negotiating trac, navigating the
route, observing trac regulations, nding a parking place, and parking
the car. In fact, while they do these complex tasks they may be tuning their
radio, listening to the news, thinking about what they intend to x for supper, and carrying on a conversation with a passenger. Eective execution
of multiple and concurrent tasks involved in driving to the supermarket
requires extensive use of executive functions, most of which operate without any conscious eort. Many other routine tasks of daily lifefor example, preparing a meal, shopping for groceries, doing homework, or par-
14
15
if one is to write productively. Grainne Fitzsimons and John Bargh (Fitzsimmons and Bargh 2004, Bargh 2005) have summarized research showing that progress on many complex tasks rests on ones ability to carry out
most of the task using such automatic self-regulation.
Executive Functions and the Brains Signaling System
Recognition of the amazing fact that executive functions generally operate
without conscious awareness oers an important caveat to my use of the
orchestra conductor as a metaphor for executive functions. Some might
take my metaphor literally and assume that there is a special consciousness in the brain that coordinates other cognitive functions. One might
picture a little man, a homunculus, a central executive somewhere behind
ones forehead, exercising conscious control over cognition like a miniature Wizard of Oz. Thus, if there is a problem with the orchestras playing,
one might attempt to speak to the conductor, requesting or demanding
needed improvements in performance.
Indeed, this presumed conductor or controlling consciousness is
often the target of encouragement, pleas, and demands by parents, teachers, and others as they attempt to help those who suer from ADD. You
just need to make yourself focus and pay attention to your schoolwork the
way you focus on those video games you love to play! they say. Youve got
to wake up and put the same eort and energy into your studies that you
put into playing hockey!
Those who care about persons with ADD and witness their poor performance in important tasks routinely prod them to deal with their impotence in the face of those tasks by insisting: Just make yourself do it! We
can all see that you have the ability. Its just a matter of realizing what is
really important and exercising willpower! Alternatively, they may impose
punishments on the person with ADD or shame them for their failure to
make themselves do consistently what they ought to do. These critics
seem to assume that the person with ADD needs only to speak emphatically
to the conductor of their own mental operations to get the desired results.
But in reality there is no conscious conductor within the human
brain. Further, each individual can only use what is made available by his
16
or her own neural networks. If the persons neural networks for executive
functions are impaired, as they are in ADD, then that individual is likely
to be proportionally impaired in the management of a wide range of cognitive functions regardless of how much he or she may wish otherwise.
There is now considerable evidence that persons appropriately diagnosed with ADD suer from signicant impairments in executive functions of the brain. These functions are not all localized in a single area of
the brain; they are decentralized, with many supported by complex networks within the prefrontal cortex. Some essential components of executive functions are supported by the amygdala and other subcortical structures, while other executive functions depend on the reticular formation
and portions of the cerebellum located in the posterior of the brain. Figure 3 in Chapter 3 shows these and other critical regions and structures of
the brain.
Complex neuronal networks link the various structures in the brain
that sustain executive functions. Rapid-re messages of input and output
travel these networks via low-voltage electrical impulses that can traverse
the entire system in much less than a millisecond. The ecient movement of these electrical impulses along the network depends on the rapid
release and reuptake of neurotransmitter chemicals, which carry each
message across synapses, or the connections between neurons, much as
a spark jumps the gap of a sparkplug.
To do this work, each of the 100 billion neurons in the brain depends
on one of the fty or so neurotransmitter chemicals manufactured within
the brain. Without the eective release and reuptake of the needed neurotransmitter chemical, that portion of the neural network cannot eectively
carry its messages. There is now considerable evidence that executive
functions of the brain impaired in ADD depend primarily, though not exclusively, on two particular neurotransmitter chemicals: dopamine and
norepinephrine.
The most persuasive evidence for the importance of these two transmitter chemicals in ADD impairments comes from medication treatment
studies. Over two hundred well-controlled studies have demonstrated eectiveness of stimulant medications in alleviating symptoms of ADHD. Al-
17
though these medications are not eective for all persons with ADHD, they
work eectively to alleviate ADHD symptoms for 70 to 80 percent of those
diagnosed with this disorder. And the medications used to treat ADHD
symptoms tend to alleviate many symptoms of ADHD simultaneously.
The primary action of medications used for ADD is to facilitate release and to inhibit reuptake of dopamine and norepinephrine at neural
synapses of crucially important executive functions. As Antonio Damasio
(1994) emphasized,
Without basic attention and working memory there is no prospect of coherent mental activity. . . . They are necessary for the
process of reasoning, during which possible outcomes are compared, ranking of results are established, and inferences are
made. (p. 197)
ADD medications help to release dopamine or norepinephrine across the
synaptic gap between neurons and to hold it there long enough to pass the
message along. Medications that do not act powerfully to facilitate release
and to block reuptake of dopamine and norepinephrine tend not to be
eective in alleviating ADD symptoms.
Improvement produced by stimulants generally can be seen within
thirty to sixty minutes after an eective dose is administered. When the
medication has worn o, ADD symptoms generally reappear at their former level. Stimulants thus do not cure ADD symptoms; they only alleviate them while each dose of medication is active. In this sense, taking
stimulants is not like taking doses of an antibiotic to wipe out an infection;
it is more like wearing eyeglasses that correct ones vision while the glasses
are being worn, but do nothing to x ones impaired eyes. This eect has
been demonstrated repeatedly in over two hundred medication treatment
studies that were double-blind: that is, neither the doctors nor the patients
knew during the study who was being given real stimulant medication
and who was being treated with placebos.
Given the often dramatic alleviation of ADD symptoms experienced
by 70 to 80 percent of persons diagnosed with ADHD when they take
stimulant medications, it is very dicult to sustain the notion that ADHD
18
impairments are a matter of a lack of willpower. Prior to beginning medication treatment most ADHD patients have made heroic, though often
erratic, eorts to improve their situation with willpower alone. Usually such
eorts barely work, if at all, and cannot be sustained.
Some argue that improvement in ADD symptoms requires not only
willpower, but also intensive behavioral treatments. Results of a major
study sponsored by the National Institute of Mental Health (MTA, 1999)
challenged this assumption. In the study, 576 children diagnosed with
ADHD were randomly assigned to one of four groups, which received
either:
Comprehensive behavioral treatment with no medication,
Carefully managed medication treatment with no other treatment,
A combination of comprehensive behavioral treatment with medication management, or
Community treatment with a pediatrician or another caregiver of the
familys choice.
The results of this study were striking. Stimulant medication alone,
carefully monitored for each child, was of signicantly greater help than
the best battery of behavioral supports that could be developed without
medication. More surprising, children who received the combined treatment (medication and comprehensive behavioral treatment) showed no
better improvement of their core ADHD symptoms than did children
treated only with carefully managed medications. Combined treatments
were more helpful with some related problems, but nonmedication treatments, even at their best, did not improve the core symptoms of ADHD anywhere near as much as did the carefully monitored medication treatment.
This study, described with many others in Chapter 9, stands as powerful
evidence that impairments of attention and memory associated with ADHD
result primarily from malfunctions in parts of the brains neural networks
that depend on the chemicals dopamine and norepinephrine.
Much more remains to be learned about how the brains complicated
neural networks operate to sustain the broad range of functions encompassed in attention. Yet it is clear that impairments of executive func-
19
tions, those brain processes that organize and activate what we generally
think of as attention, are not the result of insucient willpower. So in fact
there is an answer to the mystery of inattention illustrated by the experiences of Larry and Monica. Neural chemical impairments of the brains
executive functions cause some individuals who are good at paying attention to specic activities that interest them to have chronic impairment
in focusing for many other tasks, despite their wish and intention to do
otherwise.